Promotion of breast feeding remains the single most important nutritional intervention to improve a range of health outcomes in preterm infants
Whilst the evidence that mothers' own breast milk is best, the decision to breast-feed is a matter of individual maternal choice. National data on breast feeding rates in individual neonatal intensive care units (NICUs) is limited and not well validated, but background rates in the UK from the 2005 Infant Feeding Survey reported average initiation rates of 68%(Bolling, 2005). Demographic factors influencing the decision to breast feed are multitude and include attitudes of the wider family (partners, siblings and grandparents) and peer groups(Heinig et al., 2006), collective knowledge, and practical issues such as an ill baby(Dyson et al., 2005, Fairbank et al., 2000, Fairbank et al., 2001, Renfrew et al., 2005a, Renfrew et al., 2005b, Sikorski et al., 2003).
 Aside from improved health outcomes, the additional healthcare costs associated with NEC and poor neuro-cognitive outcome are considerable. Any increase in the marginal costs associated with increasing EBM provision need to considering, then, in the context of the additional costs to both the NHS and wider society of these, potentially preventable, adverse outcomes.

Whilst the prevalence of breast-feeding is linked to socio-economic status, mothers from less affluent backgrounds are more likely to deliver preterm or low birth weight babies who will be admitted to the NICU(Macfarlane and Mugford, 2000) .
The experience of having a sick baby admitted to a NICU means parents are thrust into an unfamiliar environment and reliant on healthcare professionals for support and guidance. Informed decision-making with regard to feeding will, in part, be dependent on the quality of information and support they receive prior to and after delivery. Failure to provide sick and/or preterm infants with expressed breast milk (EBM) on the NICU carries greater risks than for those born at term. Preterm infants who receive breast milk have better short-term (e.g. lower rates of necrotising enterocolitis, NEC) and long-term (e.g. better cognition) outcomes(Lucas and Cole, 1990, Lucas et al., 1992).

We conducted a quality improvement initiative that aimed to improve the numbers of women providing breast milk for their baby.

We've listed the 10 factors we thought were most important below (below the picture of the freezer that within weeks was too small), although they probably all worked synergistically and there may have been many other factors involved. The bottom lines are
1) if you don't measure it, you probably won't improve it and
2) if you want to improve it, you usually can.

  1. Ante-natal ward visits to offer information to mothers  likely to have a baby admitted to the NICU;
  2. Visiting all mothers as soon as possible following delivery to discuss feeding;
  3. Full supervision of first expressing session to assess technique and ensure correct information giving;
  4. Continued maternal support for first 14 days and as required thereafter;
  5. Using colostrum or EBM for mouth care/oral hygiene (whether or not enterally fed)
  6. Altering unit practice so that the default position was to give all preterm babies EBM/colostrum as soon as  available (often within the first 12-24 hours) unless medical team specifically placed a baby ‘nil by mouth’
  7. Changing unit procedures to improve the amount of time mothers  could spend providing kangaroo care;
  8. Improving NICU and postnatal staff training in line with UNICEF Baby Friendly Initiative Stage 1;
  9. Including UNICEF training on breast feeding and lactation for new medical staff ;
  10. Securing additional funding for breast pumps, considering other unit factors (e.g. screens to support expression at the cot side, or supporting mothers to express at the cot side without screens if they wished), and  improving facilities and information in the breast-feeding room
BLISS 2008. Breastfeeding and expressing for a sick and premature baby. www.bliss.org.uk

BOLLING, K. 2005. Infant feeding survey. NHS Information Centre www.ic.nhs.uk  

DYSON, L., MCCORMICK, F. & RENFREW, M. J. 2005. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews, 2.

FAIRBANK, L., O'MEARA, S., RENFREW, M. J., WOOLRIDGE, M., SOWDEN, A. J. & LISTER-SHARP, D. 2000. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technology Assessment, 4, 1-171.

FAIRBANK, L., O'MEARA, S., SOWDEN, A. J., RENFREW, M. J. & WOOLRIDGE, M. M. 2001. Promoting the initiation of breast feeding. Quality in Health Care, 10, 123-7.

HEINIG, M. J., FOLLETT, J. R., ISHII, K. D., KAVANAGH-PROCHASKA, K., COHEN, R. & PANCHULA, J. 2006. Barriers to compliance with infant-feeding recommendations among low-income women. Journal of human lactation : official journal of International Lactation Consultant Association, 22, 27-38.

LUCAS, A. & COLE, T. J. 1990. Breast milk and neonatal necrotising enterocolitis [see comments]. Lancet, 336, 1519-23.

LUCAS, A., MORLEY, R., COLE, T. J., LISTER, G. & LEESON-PAYNE, C. 1992. Breast milk and subsequent intelligence quotient in children born preterm [see comments]. Lancet, 339, 261-4.

MACFARLANE, A. & MUGFORD, M. (eds.) 2000. Birth counts: statistics of pregnancy and childbirth.  2nd ed: University of Oxford: National Perinatal Epidemiology Unit.

MIRACLE, D. J., MEIER, P. P. & BENNETT, P. A. 2004. Mothers' decisions to change from formula to mothers' milk for very-low-birth-weight infants. JOGNN Journal of Obstetric, Gynecologic, & Neonatal Nursing, 33, 692-703.

RENFREW, M. J., DYSON, L., WALLACE, L. M., D'SOUZA, L., MCCORMICK, F. & SPIBY, H. 2005a. Breastfeeding for longer: what works? Journal of the Royal Society of Health, 125, 62-3.

RENFREW, M. J., DYSON, L., WALLACE, L. M., D'SOUZA, L., MCCORMICK, F. & SPIBY, H. 2005b. The effectiveness of public health interventions to promote the duration of breastfeeding [Systematic Review]. National Institute for Health and Clinical Excellence.

SIKORSKI, J., RENFREW, M. J., PINDORIA, S. & WADE, A. 2003. Support for breastfeeding mothers: a systematic review. Paediatric and Perinatal Epidemiology, 17, 407-17.